Providers for MMA

Effective May 5, 2020, per AHCA Policy Transmittal 2020-31 related to COVID-19, all Prior Authorization requirements and service limits for all Behavioral Health Services, including Targeted Case Management, are waived until further notice. Please contact Carisk Behavioral Health at 1-800-294-8642 for any additional questions.

Below is Community Care Plan's list of MMA services that require prior authorization as of December 1st, 2018. Please be advised that effective September 1, 2020, a list of Healthcare Common Procedure Coding System (HCPCS) codes for medications requiring prior authorization has been added.

Please be advised that CCP no longer accepts authorization requests via fax. Providers will need to submit authorization requests via PlanLink, our provider portal, and should include all necessary clinical information.

Please note that all services rendered by out of network providers require prior authorization from Community Care Plan. For Behavioral Health and Substance Abuse services that require prior authorization, please contact Carisk Behavioral Health at 1-800-294-8642.

For cases where a participating provider in not available in our network or a non-participating provider is submitting the request, please use our Pre-Certification/Authorization Request Form, click here

ADMISSION INPATIENT and FACILITY-BASED CARE
ELECTIVE MEDICAL INPATIENT ADMISSION ELECTIVE SURGICAL INPATIENT ADMISSION
INPATIENT REHABILITATION ADMISSION NON-ELECTIVE (EMERGENCY) ADMISSION
NURSING FACILITY SERVICES SKILLED NURSING FACILITY ADMISSION
ADMISSION OBSERVATION
ADMISSION / DISCHARGE SAME DAY HOSPITAL OBSERVATION SERVICES (for any reason)
COSMETIC/ PLASTIC/ RECONSTRUCTIVE PROCEDURES
ADJACENT TISSUE TRANSFER/ REARRANGEMENT/ REPAIR INTEGUMENTARY SYSTEM BARIATRIC SURGERY
BLADDER REPAIR/ RECONSTRUCTION PROCEDURES BREAST SURGICAL PROCEDURES (excludes excisions or biopsies)
CANTHOPLASTY CONSTRUCT BLADDER OPENING
DESTRUCTION OF LESIONS EYELID, EXCISION AND REPAIR
EYELID REPAIR PROCEDURES FOOT and TOES RECONSTRUCTION
GASTRIC NEUROSTIMULATOR PROCEDURES GASTRIC PROCEDURES (including laparoscopic surgery and revision of anastomosis)
HAND AND FINGERS RECONSTRUCTION HEAD (SKULL, FACE, TMJ) RECONSTRUCTION
HEART DEFECT REPAIR (STRUCTURAL) HUMERUS AND ELBOW RECONSTRUCTION
INTRALESIONAL INJECTIONS KERATOPROSTHESIS
KNEE, ARTHROPLASTY LIP/ PALATE REPAIR
MASTOID SURGERY NECK AND THORAX RECONSTRUCTION
NOSE, REPAIR OCULAR ADNEXA, STRABISMUS SURGERY
PALATE AND UVULA REPAIR PELVIS and HIP RECONSTRUCTION
PENILE REPAIR SKIN FLAPS AND GRAFTS
CREATE TEAR SAC DRAIN DERMATOLOGIC PHOTOCHEMOTHERAPY AND LASER TREATMENT
TESTICULAR PROSTHESIS INSERTION
DENTAL CARE IN A FACILITY
Medically necessary dental services are authorized by the Prepaid Dental Health Plan (PDHP). CCP will be responsible for the prior authorization of the facility and ancillary medical services in the facility.
DIAGNOSTIC IMAGING AND LAB TESTING
CT SCAN (Requirement waived for high performing PCPs) CTA AND CALCIUM SCORING
GENETIC TESTING (no authorization is required for standard genetic tests performed on the pregnant enrollee) MRI (Requirement waived for high performing PCPs)
PET SCAN SLEEP STUDY
TRANSVAGINAL US NON-OB
DIALYSIS
HEMODIALYSIS AND PERITONEAL
DME FOR DURABLE MEDICAL EQUIPMENT NOT LISTED BELOW, PLEASE CONTACT COASTAL CARE SERVICES AT
1-833-204-4535
COCHLEAR DEVICE SYSTEM
DIABETIC SHOES
PATIENT LIFTS
ELECTIVE INVASIVE PROCEDURES
ABLATE HEART DYSRHYTHM FOCUS (ELETROPHYSIOLOGICAL PROCEDURES) ABLATE INFERIOR TURBINATE
ABORTION PROCEDURES (elective) ADJUST BONE FIXATION DEVICE
ANAL PRESSURE RECORD ANAL/ URINARY EMG
ARTHROSCOPY ALL BODY AREAS AV SHUNT/ ANASTOMOSIS PROCEDURES
BRONCHOSCOPIC PROCEDURES CAPSULE ENDOSCOPY
CARDIAC CATHETERIZATION CARDIOVERSION, ELECTRICAL - INTERNAL
CARPAL TUNNEL SURGERY CATARACT SURGERY (Medically necessary cataract surgery will be authorized by 20/20 EyeCare network. CCP will be responsible for the prior authorization of the facility and ancillary medical services)
CHEMODENERVE ECCRINE GLANDS CHOLECYSTECTOMY, LAPAROSCOPIC
CIRCUMCISION (AUTH REQUIRED IF AGE > 12 weeks old) CORONARY THERAPEUTIC SERVICES
CYSTOMETROGRAM CYSTOSCOPY AND TREATMENT
DENERVATION DISCECTOMY/ VERTEBRAL BODY RESECTION
ELECTRICAL STIMULATION, OPERATIVE ELECTROMYOGRAPHY and NERVE CONDUCTION VELOCITY TESTING
ENDOCERVICAL CURETTAGE ENDOSCOPY, SURGICAL (SINUS, ESOPHAGUS, SMALL INTESTINE, STOMA)
EPIDURAL INJECTION FOR LYSIS EPIDURAL INJECTION FOR PAIN
ESOPHAGOGASTRIC FUNDOPLASTY EXCISION CYSTIC HYGROMA, AXILLARY/ CERVICAL
GRAFT PROCEDURES ON MUSCULOSKELTAL SYSTEM (GENERAL) HEMORRHOIDECTOMY
HERNIA REPAIR (open and laparoscopic) HYPERBARIC TREATMENT (Wound care center only)
HYSTERECTOMY (with sterilization form) HYSTEROSCOPY
IMPLANT AND REVISION OF NEUROELECTRODES IMPLANT COCHLEAR DEVICE
IMPLANT CORNEAL RING IMPLANT CRANIAL BONE GRAFT
IMPLANT EYE SHUNT IMPLANT INFUSION PUMP
INSERTION OF TUNNELED INTRAPERITONEAL CATHETER LAMINOTOMY/ LAMINECTOMY
LAPAROSCOPY OF ABDOMEN, PERITONEUM, OMENTUM MOHS SURGERY
MYOMECTOMY NEPHRECTOMY
OPTIC NERVE, DECOMPRESSION ORAL SURGERY
ORCHIECTOMY, ORCHIOPEXY OVIDUCT/ OVARY, LAPAROSCOPY
PROCTOPEXY, LAPAROSCOPIC PENILE IMPLANT (REMOVAL ONLY)
PROSTATE PROCEDURES PTERYGIUM SURGERY
SHOULDER SURGERY/ REPAIR/ REVISION/ RECONSTRUCTION SKIN GRAFTING PROCEDURES
SPIDER VEIN AND ENDOVENOUS THERAPY SPINAL IMPLANT/ PUMP/ ANALYZE
SPINE FUSION STERILIZATION PROCEDURES (with sterilization form)
STRESS TEST (THALLIUM, CARDIOLYTE ETC.) THORACOSCOPY, DIAGNOSTIC OR SURGICAL
TOTAL DISC ARTHROPLASTY (artificial disc) TRANSCATH STENT TO CAROTID ARTERY/ INCLUDING ANGIOPLASTY
TRANSCATH PERM OCCLUSION/ EMBOLIZATION PERC, OF CNS TRANSESOPHAGEAL ECHOCARDIOGRAPHY
TYMPANOSTOMY UTERINE FIBROID EMBOLIZATION
HOME HEALTH FOR HOME HEALTH SERVICES, PLEASE CONTACT COASTAL CARE SERVICES AT
1-833-204-4535
   
HOSPICE
HOSPICE INPATIENT HOSPICE OUTPATIENT AT HOME/ ALF/ SNF
MATERNITY (Requirement Waived for High Performing OB Providers)
DELIVERY (SCHEDULED CESAREAN AND INDUCTIONS) OBSTETRICAL CARE — PRE-NATAL PROCEDURES (Prenatal sonograms do not require prior auth)
NUTRITION SERVICES
NUTRITIONAL COUNSELING NUTRITIONAL SUPPLEMENTS/ NUTRITIONAL FORMULAS/ ENTERAL NUTRITION
ORTHOTICS AND PROSTHETICS
CRANIAL ORTHOSIS LIMB AND TORSO PROSTHETICS
ORTHOTICS/ PROSTHETICS PROSTHETIC CUSTOM EYE, SURFACING & FITTING
REHABILITATION THERAPIES (PT/OT/ST). PLEASE CONTACT HEALTH NETWORK ONE AT
1-888-550-8800
THERAPY
RESPIRATORY THERAPY
INTEGRATIVE MEDICINE SERVICES
ACUPUNCTURE (Expanded Benefit—limitations apply)
CARDIAC REHAB
CHIROPRACTIC SERVICES (Prior authorization required for Expanded Benefit Only — Limitations apply)
EQUINE THERAPY
MASSAGE THERAPY (Expanded Benefit—limitations apply)
TRANSPLANT
ALL TRANSPLANT SERVICES, INCLUDING EVALUATIONS
TRANSPORTATION
AIR AMBULANCE

MMA Pharmacy Prior Authorization List

PHYSICIAN INJECTED MEDICATIONS

Code

Procedure code

Brand name

J9035

BEVACIZUMAB 10MG

AVASTIN

J0129

ABATACEPT 10MG

ORENCIA

J0476

BACLOFEN 50MCG FOR INTRATHECAL TRIAL

LIORESAL, GABLOFEN

J0475

BACLOFEN PER 10MG

LIORESAL, GABLOFEN

J0490

BELIMUMAB 10MG

BENLYSTA

J0585

ONABOTULINUMTOXINA A 1 UNIT

BOTOX

J0717

CERTOLIZUMAB PEGOL 1MG

CIMZIA

J0881

DARBEPOETIN ALFA 1MCG, FOR NON-ESRD USE

ARANESP

J0882

DARBEPOETIN ALFA 1MCG

ARANESP

J0885

EPOETIN ALFA 1,000 UNITS, FOR NON-ESRD USE

PROCRIT

J0897

DENOSUMAB 1MG

PROLIA, XGEVA

J1442

FILGRASTIM G-CSF 1MCG

NEUPOGEN

J1447

TBO FILGRASTIM 1MCG

NEUPOGEN

J1602

GOLIMUMAB FOR IV USE 1MG

SIMPONI

J1650

ENOXAPARIN SODIUM 10MG

LOVENOX

J1652

FONDAPARINUX SODIUM 0.5MG

ARIXTRA

J3262

TOCILIZUMAB 1MG

ACTEMRA

J3358

USTEKINUMAB 1MG (INTRAVENOUS ONLY)

 

J3357

USTEKINUMAB 1MG (SUBCUTANEOUS ONLY)

 

J3380

VEDOLIZUMAB 1MG

ENTYVIO

J1745

INFLIXIMAB 10MG

REMICADE

J1950

LEUPROLIDE ACETATE PER 3.75MG (FOR DEPOT SUSPENSION)

LUPRON

J2357

OMALIZUMAB 5MG

XOLAIR

J2469

PALONOSETRON 25MCG

ALOXI

J2503

PEGAPTANIB SODIUM 0.3MG

MACUGEN

J2505

PEGFILGRASTIM 6MG

NEULASTA

J2778

RANIBIZUMAB 0.1MG

LUCENTIS

Q5107

EVACIZUMAB-AWWB BIOSIMILAR 10MG

ZIRABEV

Q5105

EPOETIN ALFA, BIOSIMILAR 100 UNITS 

RETACRIT

Q5106

EPOETIN ALFA, BIOSIMILAR 100 UNITS

RETACRIT

Q5101

FILGRASTIM-SNDZ; BIOSIMILAR 1MCG

ZARXIO

Q5103

INFLIXIMAB-DYYB 10MG

INFLECTRA

Q5104

INFLIXIMAB-ABDA 10MG

RENFLEXIS

Q5108

 PEGFILGRASTIM-JMDB BIOSIMILAR 0.5MG

 FULPHILA

Q5110

FILGRASTIM-AAFI BIOSIMILAR 1MCG

NIVESTYM

Q5111

PEGFILGRASTIM-CBQV BIOSIMILAR 0.5MG

UDENYCA

J3358

USTEKINUMAB 1MG (INTRAVENOUS ONLY)

STELARA

J1453

FOSAPREPITANT 1MG

EMEND

J7324

HYALURONAN OR DERIVATIVE

ORTHOVISC

J3489

ZOLEDRONIC ACID 1MG

RECLAST OR ZOMETA

J9354

INJECTION, ADO-TRASTUZUMAB EMT 1 MG

KADCYCLA

J0378

RSV MAB IM 50 MG

SYNAGIS

J0135

INJECTION, ADALIMUMAB, 20 MG

HUMIRA

J0586

ABOBOTULINUMTOXIN A

DYSPORT

J0587

INJECTION, RIMABOTULINUMTOXIN B

MYOBLOC

J0588

INCOBOTULINUMTOXIN A

XEOMIN